​I would like to attend Chauncy Fiddle Camp!

This form must be submitted and payment must be mailed by April 1, 2018.

Permission for (name): *

Age: *

Grade in Sept. 2018: *

Gender *

Instrument: *

Years of playing in school (if any): *

Years of private lessons (if any): *

Allergies and significant medical information: *

Parent / Guardian Name(s): *

Email: *

Phone: *

By submitting this form you agree to the following:My child has permission to attend Chauncy Fiddle Camp sponsored by Elizabeth Anderson, held at 7 Chauncy St. in Westborough, June 25-29, from 9:00 a.m. to 2:00 pm. I shall make sure s/he does not attend if s/he is not feeling well.

1. In case of medical emergency, the adult in charge will attempt to contact a parent/guardian. Your electronic signature below grants permission to the physician selected by the adult in charge to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for your child if we cannot contact you. Your signature waives any responsibility for personal injury from Elizabeth Anderson or Chauncy Fiddle Camp. Please indicate all medical information and restrictions on this form.

2. Water activities are programmed daily for camp participants. Please indicate below if you grant permission for your child to swim and boat with American Red Cross certified lifeguards present. Every precaution is taken to eliminate any injury to our campers; however, water activities carry certain risks, including drowning and death. Your electronic signature hereby waives, releases, and holds harmless from any liability or claims for damages which may arise in connection to swimming or boating on Lake Chauncy, against Elizabeth Anderson, Chauncy Fiddle Camp, and its officers, agents, and employees.

Choose One *

My child has permission to participate in water activitiesMy child DOES NOT have permission to participate in water activities

3. Photos from camp may be posted for viewing online, used for promotional purposes, or distributed for private use. Please indicate below if you grant permission for photos of your child to be distributed.

Choose One *

Photos of my child may be distributedPhotos of my child MAY NOT be distributed

Date *

Parent / Guardian Signature *

During the activity I can be reached at (phone): *

Alternate phone number: *

In the event I cannot be reached, notify (name): *

Phone number of person listed above: *

Relationship: *

My child will attend: *

"Extended Camp" activities from 2-4 pm at the rate of $50 / weekSupervision during morning hours at the rate of $10 / hr.